Out as quick as you can

Capital and Coast District Health Board has, thank goodness, backed down on its silly plan to bribe new mothers to leave hospital quickly. There is a critical shortage of beds in the maternity unit in Wellington Hospital, so in order to keep enough beds available, the hospital was going to give mothers a $100 voucher if they left within six hours of giving birth. The target group was second time mothers, people who already know a little bit about how to look after new born babies.

A moment’s reflection tells you why this was a silly plan. The risk is that people who still need trained care and assistance would choose to leave the maternity ward, even if they were not well. A very poor health outcome, for mothers, and for new born babies.

The bribe is gone now, but not the pressure for women to leave hospital early. If you read the article, you will see that lead maternity carers get an extra payment if women leave hospital early, and that hospital staff are still under pressure to keep women moving out.

This is anti-women, and anti-family. I have written before about the difficulties of sending new mothers home within hours of birth, in connection with establishing breastfeeding.

Rooming in looks very nice, but there’s a big problem with it. Although it is phrased as “allow”, in practice, it becomes, “mothers and babies must be kept together”. So a woman who has been through an exhausting delivery will nevertheless not be given any chance to sleep, because the nursing staff won’t help her to settle her baby, and won’t consider taking the baby into a nursery even just for a while, to allow the mother to sleep. The baby can always be brought back to the mother when it wakes, so there’s no lack of breastfeeding. However, it does take staff time to manage a nursery. So babies must stay with mothers, even at the cost of the mother’s exhaustion. This is a worse problem if the mother is heading home to other children. Unless she has a partner who has time off work, or family nearby, she will be required to look after those children too. So her brief time in hospital really is the last chance she will have to get a decent rest for weeks, if not months. And surely, that must have a bad effect on babies.

And I just don’t see how any hospital which encourages new mothers to leave after just two or three days could possibly be described as a “baby friendly” hospital. Breastfeeding is a learned skill. Some women and babies find it very, very easy, but others don’t, at all. They need help and support, especially in those early few days, when they are tired from the processes of giving birth and being born. By about day three, a new mother’s milk will be coming in, so she and her baby will be getting used to an entirely new process, but that’s almost exactly when hospitals kick mothers out the door. New mothers need to be able to stay in hospital, where they can rest, and where they can get help, for more than just a few days. To my mind, to deserve the title, “Baby Friendly”, a hospital needs to encourage women to stay for five or six or even more days after birth, if that’s what they need. And in order for that to happen, hospitals need to be properly funded.

The solution to funding pressures is not to refuse to treat patients. Let’s see if we can think of other ways that funding pressure could be reduced by not treating people. Maybe kids with broken bones could be sent home to see if they really need hospital treatment. Middle aged men with chest pains could be told to wait a few days, just to see if it really is a heart attack. Perhaps people could be discharged straight out of operating theatres, if they feel that they really have come through surgery quite well.

One of the difficult aspects of this whole episode is that any woman who is due to give birth at Wellington Hospital in the next few months must now be feeling quite nervous. This will affect my family – my brother and sister-in-law have a baby on the way, and they are due to give birth there sometime in January, all going well.

Please, if you have a partner, a friend, a sister, a daughter, a daughter-in-law, who is due to have her baby at Wellington Hospital sometime in the next few months, be there for her. Be there to fetch, run and carry, to sit by her bedside and look after her, to make sure that hospital staff don’t put pressure on her to leave too early.

Of course, that’s the sort of thing that families and friends do in third world hospital systems. We have always liked to think we are a bit better than that, but perhaps we are not. And that’s perhaps the most disturbing aspect of this whole story, that we simply can’t rely on our health system to provide a decent standard of care.

19 responses to “Out as quick as you can”

>Please, if you have a partner, a friend, a sister, a daughter, a daughter-in-law, who is due to have her baby at Wellington Hospital sometime in the next few months, be there for her

I would second that. I had a terrible time at Wellington Hospital. I had a caesarian and it is really difficult to move around at first but I was left alone with the baby and had to get in and out of bed and lift her and do all the necessary by myself.

I was also taking a lot of drugs and antibiotics because of who the birth went down. Nobody made sure I’d had food so I ended up vomiting a few times completely unnecessarily.

And both my daughter and I were on drips which ended up getting bloody and infected because none of the staff were paying attention. I didn’t care about myself that much but seeing a bloody (literally) needle stuck in my precious 3 day old’s little arm was horrible.

I really felt much more traumatised by the after “care” in the hospital than the birth to be honest.

All of this makes me nervous, even though I’m not going to be birthing in Wellington Hospital. The clinic my midwife operates at seems to be of the general opinion that you should be home as soon as possible, unless there is a good reason not to. I’m not sure what qualifies as a “good reason” yet, but we are doing the birth plan next week so hopefully I’ll find out then. They seem to think that a) hospital is a less hygenic place to be than home (which is interesting because most hospitals seem to have an entirely separate area for maternity) and b) it is just better for everyone to be at home. To which my response is well possibly, if you have the support at home (which I will, but I still feel uncomfortable about being turfed out potentially within 6 hours of having given birth for the first time in my life).

My midwives are also against me going into Birthcare for the birth, instead of a hospital environment, saying that it isn’t good for first time mums. So basically they leave me with one option – go to hospital and then go home asap.

I’ve worked out in the last month that I probably shouldn’t have gone with these midwives, but it is far too late to change now.

Margaret- sorry to freak you out. It is very likely your birth will all go smoothly and you won’t have a bad experience in hospital. I think I was particularly unlucky as I was there at a time when they were very understaffed. And, all though pretty ghastly at the time, it was only a few days out of my life which are now ancient history. I made a conscious decision that I was not going to let the rough start define or ruin my experience of motherhood and it hasn’t.

All I know is that up until about 5 years ago, my ex-wife was working as a hospital midwife in Wellington Hospital. They were short-handed enough that they rarely took the leave they were entitled to, for fear of letting down their colleagues, and then ended up taking sickies instead, which rooted the rostering far worse than if they had taken the leave they needed in the first place. The pay was crap, the working conditions antiquated, and the staff turnover high. I would say the stress of working there was one of the contributing factors in our breakup.

I hope that things have improved there since. I kind of doubt it though.

I pointed my ex at this discussion, and she emailed me as follows (she lives in Australia now, still working as a hospital midwife):

I’m a perfect example of how the ‘brain drain’ affects NZers. Here I earn more money (slightly more), pay less tax, have a better lifestyle and have had a significant promotion at work. Midwifery here still sucks, the shortage isn’t national it’s international. Joe Public has no concept of our working conditions, pay rates (I could almost earn the same working in a shop), yet they come to hospital expect us to be able to respond in life or death situations and fetch them a glass of water. I can totally understand why young people now don’t want to train to be midwives. The shortage in only going to get worse and worse….midwives are an aging population, average age is about 40ish. What will it be like in 20 years time?? Not better or the same than it is now I promise. No-one is addressing the situation at a long term level.

Han sees how I work and would never ever consider becoming a midwife. Who will look after her generation when they have babies. Working night shift every four weeks…that’s 3 off 1 on for nights, I’m getting too old for that and am looking at leaving clinical work in the next two years.

However, I also believe in early discharge, hospitals are the perfect place to get sick. Want your new baby to end up with formula or IV antibiotics? Stay in hospital! But it needs to be supported with really good care bat home…I agree that food vouchers or nappies are a poor substitute for midwifery care at home. In Australia it’s worse than in NZ< here women get one maybe two visits at home after discharge.

Don’t worry Make Tea, I’ve heard plenty of good birth stories recently too. My reservations about my own midwife (actually more about the back-up midwife who heads the clinic) have pre-dated this recent news about Wellington Hospital.

Stephen, I have a lot of respect for midwives and I’m not generalising about them all from my own experience. I think I just happen to have picked a clinic that is a bad match for me. I suspect that you are quite correct, that the problems that arise are much more to do with the systems in place than the individuals who do their best within those systems.

My question is a little more indirect and it is this, how do you introduce innovation into this important area when, at any time someone can step in and say “but if you do this, you risk the health or even death of the patient !” ?

My experience is that the health sector is years behind other industries in even ordinary best practice approaches. In health it is very easy to criticize customer incentives (especially financial ones) that can help the optimise service provision that are common in other areas (“pizza’s on $6 IF YOU PICKUP”, “travel off-peak and get %30 a discount”). The result is, well what you get now, waiting lists, patients who are clinically well occupying beds and health providers who know full well what is needed continuing to operate with one hand tied behind their back.

It IS a difficult area to work as the consequences of getting things wrong are huge. But the political nature of health management means that any initiative that is focused on that horrible phrase “efficiency improvement” is almost impossible to implement on the apparent assumption that they always lead to lowered healthcare standards. What is not so obvious is the extra health provision then able to be provided by a the more efficient use of current resources . . . the real outcome of the constant killing of efficiency inside the hospital is the avoidable death of people still waiting to get in😦

Tony, the problem lurking there is that with the kinds of incentives you describe, the customer/patient has to make the assessment as to whether their problem is serious or not, and hence whether the offered incentive is worth it to them – yet they may well be unable to make that assessment and in fact why they have presented themselves in the first place. Given that, it follows that you simply can’t get rid of people without a trained person assessing them first, and you must look elsewhere for your efficiencies.

You say “the real outcome of the constant killing of efficiency inside the hospital is the avoidable death of people still waiting to get in.” My suspicion is that if you gained that efficiency inside, we would then be concerned about the avoidable killing of people ejected from or deterred from entering the hospital. Which in turn suggests to me that at a global level, the system is as efficient as it can be, and further improvements can only be achieved by increasing capacity.

I wonder howmuch the physical environment at Wellington Hospital affects the midwifery staff. The wards are old-fashionbed and clunky, with four beds in each room – very difficult for new mums tryng to get some sleep, and trying to get up to tend their babieis without disturbing the other women, bathrooms are communal and can be some distance from bedrooms, the lighting is poor, the corridors are big and instutional, and somehow frightening. All quite a contrast to Palmerston North hospital, where my twins were born. The ward there has configurations of one and two bed rooms sharing a bathroom. New mums are in reasonable comfort there. It does seem that the staff there are happier, even though they may be just as hardpressed as the Wellington staff, simply because they have a much better environment.

Margaret – I will be thinking of you. It should all be just fine – most births are. And that support at home is what makes a big difference in the first few days. We had my mother with us for the first few days after each birth – and that really helped. And after our twins were born, she and Dad came down to see us regularly, with chillie bins full of frozen meals – bless them. My Dad’s home made pasta is always good, and it was just what we needed at the time.

You will let us know how it goes…?

My young next door neighbour came home just a few hours after her first baby was born. But… her mum is a Plunket nurse, and was a midwife.

Thanks for the kind wishes Stephen and Deborah. I am reasonably relaxed about it, but it does hit an emotional nerve at the moment, for obvious reasons!

Stephen I unfortunately work with one of those people who like to tell horror stories. She drives me nuts. Luckily I have only two more weeks of her company to endure! And I think she is on leave for most of that time, phew🙂

I have found ante-natal classes very useful in managing my expectations about the birth process, as well as a few good friends who have answered my silly questions and been very honest with me without being scary.

It seems to me that we have come a long long way in terms of infant and mother mortality. Whatever bad experiences NZ mums may have in maternity wards at least we generally all live! Improvement should be continual, but I can’t help thinking about a relative who had a transverse breech baby – 150 years ago both she and the baby probably would have died, whereas now it’s not even a particularly big deal.

We spent some time in Wellington’s children ward when our son was born. The impression we got was of good people doing their best in a grotty situation. They will look after you as best they can Margaret.
As Merc says, why does their work get so undervalued?

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